TUBERCULOSIS: A Cultural History of Tuberculosis in Modern Japan

FUKUDA Mahito
More than any other disease known to man, tuberculosis (kekkaku) has been endowed with a romanticized, aesthetic image, despite the horrible agonies suffered by those afflicted. Tuberculosis is known to have been one of the oldest diseases of mankind. However, it is not known how prevalent it was before the advent of vital statistics in England in the middle of the seventeenth century. The same was true of Japan before official statistics began in 1900.
Although it was known as Rogai (consuming and coughing) before the Meiji Restoration in 1868, the Japanese did not leave any death records except for the few records still extant in some local temples. Tuberculosis was thought to be particularly prevalent among upper-class daughters and highly talented young men. However, after the Meiji Restoration, due to the nation's drastic modernization, industrialization and urbanization, it became disastrously prevalent under the new name, Haibyo (lung disease).
The Meiji Restoration introduced western scientific ideas including medical knowledge. Fundamental change occurred when the decision was made instituting the Isei (Medical System) in 1874 to adopt western medicine as the orthodox approach in the new Meiji regime.
Under the Shokusan-kogyo (Increase in Production and Promotion in Industry) and Fukoku-kyohei (Enrich the Country and Strengthen the Army) policies, Japan exerted herself to catch up with the industrialized countries in the West. In the course of this process bad working conditions (typically seen among female mill hands), long working hours, polluted, unsanitary conditions, unnutritious diet, and so forth were particularly prevalent. Therefore, high morbidity and mortality resulted. The main cause of death was tuberculosis, and the afflicted were easily expelled from the factory without sufficient medical care or financial support. Either they went home where the disease was still rare, thus spreading tuberculosis among their neighbours, or they became dwellers of the urban slum. It was no wonder that the disease spread so widely in such a short period of time. ISHIHARA Osamu, the forerunner of public health in Japan, wrote an epoch-making book on workers entitled Joko to kekkaku (Female Mill Hands and Tuberculosis) in 1915.
The first national census was taken place in 1900. However, the hygenic statististics which had already begun in 1877 included the number of patients and deaths from respiratory diseases. Statistical data on Haibyo began to appear in the official data book in 1883, just one year after the discovery of the tubercular bacillus by Robert Koch, the German bacteriologist.
All these data suggest that the morbidity and mortality from tuberculosis gradually increased year by year, thanks partly to modernization, and partly to the insufficient knowledge of and medical remedy for this disease. Although in 1896 Wilhelm Conrad Roentgen discovered the X-ray which would certainly become one of the most valuable diagnostic methods, it was some while before it would be put into practical use. In the world's slums, including that of Japan, formerly unaffected people in uncontaminated areas (so-called "virgin soil") would often experience drastic symptoms, such as miliary tuberculosis and galloping tuberculosis, and widespread of tuberculosis.
One of those who described the fight against tuberculosis and was himself a tubercular patient was Dr. MORI Rintaro (whose pen-name was MORI Ogai), one of the most outstanding novelists of modern Japan. In his youth, he suffered from pleurisy and later studied abroad in Germany from 1884 to 1888 under the supervision of Dr. M. VON PETTENKOFER and Dr. R. KOCH, who had already discovered the tubercular bacillus in 1882. He played a key role in introducing Tuberkulin (Tuberculin) to Japan, invented by KOCH in 1890 as a final remedy for tuberculosis, through his medical journal. However, it turned out to be not only useless, but also harmful to the patients.
However, Ogai continued to hide the fact that he was tuberculous to the end of his life, knowing how dangerously infectious it is if unattended. Although he did not openly delcare that he was tuberculous, some descriptions of tuberculosis and tuberculous patients are found in his novels and dramas. In his drama Kamen (The Mask, 1909), Ogai, in the disguise of a practicing doctor, confessed how he secreted his disease like a hero in the middle of the crowds. In his novel Vita Sexualis (1909, heavily censored by the authorities) he described how he got rid of the prostitutes in Munich (Muenchen): all he had to do was to shout that he was tuberculous. Ogai divorced his own first wife on account of her illness, tuberculosis, without mentioning it. When he came to know that one of his young acquaintances, HATORI Chihiro, died of tuberculosis, he could not help writing a monody in honour of him and sending a copy of the magazine to his mother, even on the day after the demise of the Meiji Emperor. Considering that he was hastily writing an important novel inspired by the news of the General Nogi's loyalty suicide on the demise of the Emperor, his profound sympathy with Hadori's death becomes abundantly clear.
Ogai hid his secret in order to protect his family's honour: in those days once it was known that somebody was tuberculous, members of the whole family would often be discriminated against so severly as to be unable to get married. However, we have to bear in mind that he was always careful not to spit sputum in public places. Even at home, he would gather the papers after wiping his mouth and burn them.
It is often thought that only in the West, particlularly during the Romantic era, did tuberculosis take on an aura of romance. This, however, was not the case.
Even in Japan, the "look" of tuberculous patients was held to have a special allure for women; it even attained the stature of a category of beauty. The romanticized literary vision of tuberculosis taking the most talented and beautiful flourished among Japanese people from 1889 when TSUNASHIMA Ryosen worte Zangiku (Chrysanthemum Remained). The story is about a young wife dying from consumption and whose husband is studying abroad in the US. However, when her beloved husband comes back, her disease is miraculously cured. It was widely read and welcomed.
In 1898 TOKUTOMI Roka wrote Hototogisu (Nightingale), which actually described tuberculosis as a demonic disease which strikes down a fair, pure and affectionate woman. Some of the factors in the story such as its background of elitist society, disharmony between mother and daughter-in-law, and separation due to the Sino-Japanese war, contributed to its enormous popularity and more than 100 impressions being made within ten years. And this popularity profoundly influenced the formation of aesthetic images pertaining this deadly disease.
The real-life models for the novel were themselves members of the elite of the Meiji regime. The heroine was a daughter of a field marshal ; the hero, a son of a governor, who later became the chief director of the Bank of Japan. Among other models for the novel were two doctors (also part of the Meiji Era elite), one of whom was the Medical General of the Imperial Army, and the other of the Navy.
Romanticization of tuberculosis, or endowing it with aesthetic images continued for decades. Even MORI Ogai, despite his rather uncomfortable experience as a tubercular, he could not but stand with the romanticization of the disease by translating Arthur Schnitzler's Der Sterben (The death, 1894, tr. as Miren in 1912), depicting the tragic dolce vita of a tubercular patient, the novel would greatly influenced HORI Tatsuo who might be called the centre figure in the "sanatorium literature" in Japan.
Yet another figure important in confirming this aesthetic image of tubercular women was TAKEHISA Yumeji, the poet, writer, painter and woodblock artist who exerted great influence throughout the Meiji, Taisho and Showa eras.
In prewar and even early postwar Japan, many letters and diaries display this attitude toward tuberculosis, despite its grim and awful reality. The popularity of such sea resort areas as Zushi, Kamakura and Chigasaki can be traced back to TOKUTOMI'S Hototogisu. In fact, tuberculosis dates back to pre-modern times : diligent students and the beloved daughters of wealthy seventeenth century families were purported to be infected with tuberculosis. This kind of conceptualization made it a topos not only in modern society but also in the feudal era long before the arrival of such Western notions as Romanticism.
In spite of this general inclination, MA5AOKA Shiki, a haiku poet fatally afflicted with tuberculosis for more than thirteen years displayed few of these romantic ideas concerning the disease. Neither did his close friend NATSUME Soseki, the celebrated novelist, who lost his mother and two brothers to tuberculosis before contracting it himself. Shiki continued to write his essays filled with his everyday observations and thoughts until three days prior to his death. In his destitution, his long agony and fear, he aestheticized the pathos of his daily suffering and wrote longingly of his desire to see the new marvels of the modern age, the bicycle, the red postboxes and the motion picture machines.
As it was first of all difficult for the doctors to diagnose it correctly, Shiki was given several different diagnoses for his disease and prescribed various medicines. Secondly, it was quite likely that doctors did not disclose the true identity of the disease to the patients in order to soften the shock as with cancer today. Thirdly, in order to keep his patients, a doctor would often soothe them with comfortable lies. Even at the turn of the century, more than eighteen years after the discovery of the bacillus, it was still subject to varying winds of medical opinion. Although the detailed examination of the chest by applying the physical examination such as auscultation, percussion and pulse-taking were in use, controversey continued between those supporting the contagionist position and those proclaiming the primacy of heredity.
For those told of their tragic reality by the doctors, their only hope for recovery was to take open air treatment under the strict supervision of the doctors in sanatorium. As time passed, treatment evolved from merely a "changing of air", -such as going to the countryside on weekends-, to going to certain noted sea resorts, mountain camps, or spas noted for the medicinal effect of their waters. Japan has a long tradition of spa-going, such places as Kusatsu or Atami, where people bathed and took the waters as they did in Baden-Baden, Karlsbad in Germany or Royal Tunbridge Wells in Britain. In antiquity and the Middle Ages, sea-bathing was once commonly applied to the feeble and the disabled in Japan, but in more recent times somehow it became utterly forgotten or medically ignored as a means of treatment
Under the influence of Western medicine, Japanese doctors began to search for disirable places for their patients with the German doctor Erwin von Baelz. He walked around looking for good spas such as Kusatsu and Hakone, and also wanten to establish a mountain sanatorium for the tuberculars. This activity was taken ovei by the Japanese, and the Kamakura Sea Hospital was founded by NAGAYO Sensai who incidentally coined the word Eisei (hygiene) in 1887, and by TSURUSAKI Heizaburo of the Sumaura Hospital in 1889. After these two pioneering sanatoria, many others were established mainly at the sea coast. These sanatoria were, however, initally private ventures run for profit or institutions supported by religious or charitable organizations.
The first municipal dispensary, Toneyama Dispensary, reserved exclusively for the tuberculars was opened in Osaka in 1915 in accordance with the promulgation of the "Regulation Concerning the Foundation of Tubercular Dispensary and State Subsidy." This was followed by the Tokyo Dispensary, and then dispensaries in Kyoto, Kobe, Yokohama and Nagoya.
The first sanatorium at a high altitude, Fujimi Alpine Sanatorium, was opened by MASAKI Fujokyu in 1925. The great therapeutic advantage of fresh air was deeply appreciated along with a supply of nutritious food, rest and constant medical supervision.
Many tuberculous patients including novelists and artists gathered together in such sanatoria in Chigasaki, Kamakura and Boso Peninsula (sea areas), and Karuizawa, Fujimi and Kiyosato (mountain areas). In the course of climatic therapy, new methods such as therapeutic pneumothorax and collapse therapy were introduced. Mass screening using X-rays and Tuberculin actually discovered many latent sufferers among the people. And in Japan, BCG was particularly used as prophylactic measures. However, due to the advent of antibiotics, Streptomycin, in 1944, all those surgical operations and open-air treatment became abruptly extinct.
Paralleling these advances in the scientific treatment of tuberculosis, the disease has long been the focus of folk medicines, many of them bogus. At the same time, many popular books and magazines on treatment were widely circulated purporting that there was no effective remedy for tuberculosis and that there were not enough hospital beds for the patients. Such issues are dealt with at length in this book. National preventive movements, particularly in Japan, and the issues of genetic immunity accoding to places and races are also covered.
My book represents an effort to trace the cultural history of tuberculosis, particularly in modern Japan, and as such I believe it may represent an initial attempt to pry open a hither-to neglected dimension of modern Japanese history. In general, as can be seen in similar studies of the (still short) cultural history of AIDS, this is an area of study whose possibilities are just now being explored.

(Dr. FUKUDA, Professor, Graduate School of Languages & Cultures, Nagoya University, Nagoya 464-8601, JAPAN)

http://www.lang.nagoya-u.ac.jp/~mfukuda/english.html